Community Care

Policy and Practice

Robin Means, Sally Richards, Randall Smith

• Publisher: Bloomsbury Academic
• Year: 2008
• ISBN:
  9781350311862
• Edition: 4
• Topic: Politics & International Relations
• Subtopic: Public Policy
• Index: Politics & International Relations

This new edition has been updated to reflect recent shifts in community and social care whilst still providing the authoritative account of its historical development. Particular attention is paid to partnerships between health and social care, the regulation of social care, direct payments and individual budgets and user/carer empowerment.

Chapter 1

Introducing Community Care

The first two editions of Community Care: Policy and Practice focused upon progress and problems in the implementation of the far-reaching changes introduced by the National Health Service and Community Care Act 1990. The 1990 Act had given the lead agency role to social services authorities for all the main ‘core’ groups of service users and required the stimulation of a mixed economy of care through encouraging independent providers. At a strategic level, this was to be achieved through the publication of community care plans on the basis of wide consultation with key agencies and groups, including service users and carers. Care management was to be used at the operational level to ensure service users were offered flexible packages of care which were to draw heavily upon the independent sector.

The third edition was published in 2003 and continued to focus on the 1990 Act but in the context of eight years of Labour Government. By 2003, three themes were beginning to dominate, namely:

• the growing emphasis by the government upon user empowerment;

• the speed of policy change leading to implementation problems which we called ‘modernisation muddles’;

• the growing emphasis upon the pivotal role of health/ primary care leading us to question whether it would soon be ‘the end for social services’ as the lead agency in community care.

These three themes lie at the heart of this fourth edition. How far is the government willing to push its commitment to user empowerment? Has the pace of policy change slowed and are the numerous changes beginning to finally ‘bed down’? Is it no longer appropriate to think in terms of lead agency roles in community care?

These crucial questions will be tackled by providing both a critique of key policy documents such as the Green Paper on Adult Social Care (Department of Health, 2005a) and also a review of the research evidence. However, as with previous editions, this one will be set within a context that is much wider than just contemporary community care policy and practice in the UK. This broader context will embrace historical perspectives (how much change is really occurring?), comparative perspectives (what is happening in other countries?) and theoretical perspectives (can we understand what is happening more clearly by drawing upon theories and organisational developments from outside community care?).

The third edition concluded with the following comments:

New Labour’s programme of modernisation seeks to achieve quality services that put the interests of the service user first. Whether this can be achieved by the top-down implementation of the current plethora of reforms and initiatives is likely to form the subject of any future edition of this book. (Means et al., 2003, p. 222)

The overall task of the fourth edition is to assess whether such quality services have emerged or whether confusion remains the dominant feature of the community care policy and practice landscape in the UK.

What is community care? What is social care?

Since the late 1960s, community care has come to be almost universally espoused as a desirable objective for service users and a central pillar of policy for governments and politicians of all persuasions. An obvious starting point is for the authors to offer a clear statement about what they understand by the term ‘community care’. Which groups will be covered? Will the book cover unpaid care as well as paid care? Does it include institutional care as well as domiciliary services? Which health care services are included? What does ‘community’ mean in the context of the term ‘community care’? How does ‘community care’ relate to the growing use of the term ‘social care’ by government? These are simple questions but do they not necessarily have simple answers. ‘Community care’ has long been a contested term used by different people in different ways at different points in time.

The starting point in this definitional quest has to be the loaded power of the word ‘community’ within the term ‘community care’. Titmuss (1968) described community care as ‘the everlasting cottage-garden trailer’ and went on to remark:

Does it not conjure up a sense of warmth and human kindness, essentially personal and comforting, as loving as the wild flowers so enchantingly described by Lawrence in Lady Chatterley’s Lover? (p. 104)

But where does the positive power of the term ‘community care’ come from? Baron and Haldane (1992) argued that it flows from the fact that ‘community’ is what Raymond Williams (1976) called a keyword in the development of culture and society. From the ninth century BC through to the twentieth century AD, Williams traced the use of the term ‘community’ to grieve for the recent passing of a series of mythical golden ages; each generation perceiving the past as organic and whole compared to the present. As Baron and Haldane point out, the term ‘community’ thus enables ‘the continuous construction of an idyllic past of plenty and social harmony which acts as a critique of contemporary social relations’ (p. 4). Thus the call by politicians and policy-makers to replace present systems of provision with community care feeds into this myth by implying that it is possible to recreate what many believe were the harmonious, caring and integrated communities of the past.

Taylor (2003) argues that it is possible to identify three different uses of the term community:

• descriptive: a group or network of people who share something in common or interact with each other;

• normative: community as a place where solidarity, participation and coherence are found;

• instrumental: (a) community as an agent acting to maintain or change its circumstances; (b) the location or orientation of services and policy interventions. (p. 34)

This perspective helps to explain the popularity of policy initiatives such as community care, community schools and community policing with politicians and policy-makers. Such policies use community in an instrumental way, justified by descriptions of community which stress their assumed normative strengths. Indeed, a strong feature of the Labour Governments since 1997 has been the stress upon neighbourhood and community renewal from a belief that ‘healthy’ communities are a prerequisite for a successful society (Department of Communities and Local Government, 2006). A key objective of this book is to delve behind the rhetoric of community care and caring communities. For example, several authors have pointed out that individuals and not communities carry out caring work, and that unpaid care is primarily carried out by female relatives (see Chapters 2 and 7). Equally, most people, including the users of community care services, have a highly complex notion of community. For some it is a small number of local streets, and for others their sense of community may come from work or leisure networks which are not geographically based (see Chapter 6). Indeed research suggests that as many as one in three people have no strong attachment to the ‘community’ in which they live (Taylor, 2003). Equally the provision of community care services based on local authority boundaries rarely reflects how service users perceive community. A day centre may not seem like a community service to a user if they have to travel three miles by specialist bus to reach it.

An important starting point for this analytical approach to community care is to trace the emergence of the term and its changing use over time. Yet it is very difficult to pin down the exact source. In a 1961 lecture delivered to the National Association of Mental Health, Titmuss (1968) claimed he had tried and failed to discover in any precise form its social origins, but went on to reflect that:

institutional policies, both before and since the Mental Health Act of 1959, have, and without a doubt, assumed that someone knows what it means. More and more people suffering from schizophrenia, depressive illnesses and other mental handicaps have been discharged from hospitals, not cured but symptom-treated and labelled ‘relieved’. More and more of the mentally subnormal have been placed under statutory supervision in the community. (p. 105)

Titmuss’s concern was that the reduced reliance on hospitals would not be balanced by a major expansion of community-based services. In the following year, the then Minister of Health, Enoch Powell, took the ‘policy’ of community care one stage further with his 1962 Hospital Plan, which launched an official closure programme for large mental health and mental handicap hospitals and their replacement by a network of services to be provided in the community by local health and welfare services.

Although the origins of the phrase are obscure, it is clear that the term ‘community care’ was initially used to refer to a policy shift away from hospitals and towards community-based provision for ‘mentally handicapped’ people and for people with mental health problems. However, it soon began to be used in reference to the provision of services for elderly people and for physically disabled people. For example, the Chief Welfare Officer at the Ministry of Health was claiming in 1964 that with regard to older people:

the true centre of the picture so far as geriatric services are concerned really has shifted, or is rapidly shifting, to care in the community supported by domiciliary services, and the important thing is to remember that residential homes are in fact a vital and most important part of community service. (Aves, 1964, p. 12)

The context of this quotation was government concern about the cost of long-term hospital care for frail elderly people. The Chief Welfare Officer was justifying a move to a cheaper form of institutional care (local authority residential care) by referring to it as a community service.

However, residential care in the 1970s was itself being seen by many as an overly expensive form of provision, which consumed resources that would be better employed funding non-institutional services such as home care, day care and sheltered housing (Bosanquet, 1978). A Happier Old Age, a discussion document produced by the then Labour Government (Department of Health and Social Security, 1978a) called for a major expansion of such services to keep the majority of frail elderly people out of expensive local authority residential care.

In the 1980s the definition of community care seemed to have been tightened by central government yet again. The White Paper response, Growing Older, to the discussion document was produced by a Conservative rather than a Labour government. It argued that:

whatever level of public expenditure proves practicable and however it is distributed, the primary sources of support and care for elderly people are informal and voluntary … It is the role of public authorities to sustain and, where necessary, develop – but never to displace – such support and care. Care in the community must increasingly mean by the community. (Department of Health and Social Security, 1981, p. 3)

The overall message was that community care (that is, informal care) needed to be maximised, partly because it was cheaper than care based on state-provided domiciliary services. By this definition, community care becomes what Abrams (1977, p. 151) called ‘the provision of help, support and protection to others by lay members of societies acting in everyday domestic and occupational settings’.

In the past, therefore, the term ‘community care’ has been used to argue for changes in service emphasis. The positive virtues of community care have been juxtaposed against expensive, rigid and bureaucratic alternatives, such as hospitals, care homes and sometimes even domiciliary services. However, the 1989 White Paper Caring for People (Department of Health, 1989a) took a very different approach by referring to the full spectrum of care and services received by certain groups as being what it meant by community care:

community care means providing the right level of intervention and support to enable people to achieve maximum independence and control over their own lives. For this aim to become a reality, the development of a wide range of services provided in a variety of settings is essential. These services form part of a spectrum of care, ranging from domiciliary support provided to people in their own homes, strengthened by the availability of respite care and day care for those with more intensive care needs, through sheltered housing, group homes and hostels where increasing levels of care are available, to residential care and nursing homes and long-stay hospital care for those for whom other forms of care are no longer enough. (p. 9)

The White Paper explains that its focus is mainly upon the role of the statutory and independent sectors but that ‘the reality is that most care is provided by family, friends and neighbours’ (ibid.). The statutory and independent sectors are seen as responsible for providing social care (including housing), health care and appropriate social security benefits. This book takes a similarly broad view of what is meant by the term ‘community care’. It thus considers not only informal support by unpaid carers but also the provision of the full spectrum of institutional and non-institutional services by the public, private and voluntary sectors.

A final definitional complication has emerged in recent years because of the growing use of the term ‘social care’ rather than ‘community care’ by the government. Thus, 2005 saw the publication of a Green Paper on Adult Social Care (Department of Health, 2005a) rather than on community care or adult community care. Rather like Titmuss’s search for the origins of community care, we have not been able to trace the first ‘official’ use of the term ‘social care’ let alone a clear rationale from government for it being preferred over ‘community care’. In other words, what did ‘community care’ do wrong? Although, there is no definitive answer to this question there is a strong suspicion that the driver relates to the lead agency role of social services in community care (see Chapter 3). By using the term ‘social care’, this apparent policy commitment can be sidestepped rather than officially reversed. A good example of this was Shifting the Balance of Power within the NHS: Securing Delivery (Depart...

Table of contents

• Cover
• Title Page
• Copyright
• Contents
• List of Tables, Figures and Boxes
• Preface
• Acknowledgements
• 1. Introducing Community Care
• 2. From Institutions to Care in the Community: The History of Neglect
• 3. Implementing the Community Care Reforms
• 4. Community Care and the Modernisation Agenda
• 5. Health and Social Care: From Collaboration to Incorporation?
• 6. Housing and Community Care
• 7. Community Care: User Empowerment
• 8. International Perspectives on Community Care: Lesson Drawing or Policy Learning?
• 9. Community Care: New Directions and Old Challenges
• Guide to Further Reading
• References
• Index